Michael A. Kohn

Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments

CONTEXT National quality improvement initiatives implemented in the late 1990s were followed by substantial increases in opioid prescribing in the United States, but it is unknown whether opioid prescribing for treatment of pain in the emergency department has increased and whether differences in opioid prescribing by race/ethnicity have decreased. OBJECTIVES To determine whether opioid prescribing in emergency departments has increased, whether non-Hispanic white patients are more likely to receive an opioid than other racial/ethnic groups, and whether differential prescribing by race/ethnicity has diminished since 2000. DESIGN AND SETTING Pain-related visits to US emergency departments were identified using reason-for-visit and physician diagnosis codes from 13 years (1993-2005) of the National Hospital Ambulatory Medical Care Survey. MAIN OUTCOME MEASURE Prescription of an opioid analgesic. RESULTS Pain-related visits accounted for 156 729 of 374 891 (42%) emergency department visits. Opioid prescribing for pain-related visits increased from 23% (95% confidence interval [CI], 21%-24%) in 1993 to 37% (95% CI, 34%-39%) in 2005 (P < .001 for trend), and this trend was more pronounced in 2001-2005 (P = .02). Over all years, white patients with pain were more likely to receive an opioid (31%) than black (23%), Hispanic (24%), or Asian/other patients (28%) (P < .001 for trend), and differences did not diminish over time (P = .44), with opioid prescribing rates of 40% for white patients and 32% for all other patients in 2005. Differential prescribing by race/ethnicity was evident for all types of pain visits, was more pronounced with increasing pain severity, and was detectable for long-bone fracture and nephrolithiasis as well as among children. Statistical adjustment for pain severity and other factors did not substantially attenuate these differences, with white patients remaining significantly more likely to receive an opioid prescription than black patients (adjusted odds ratio, 0.66; 95% CI, 0.62-0.70), Hispanic patients (0.67; 95% CI, 0.63-0.72), and Asian/other patients (0.79; 95% CI, 0.67-0.93). CONCLUSION Opioid prescribing for patients making a pain-related visit to the emergency department increased after national quality improvement initiatives in the late 1990s, but differences in opioid prescribing by race/ethnicity have not diminished.

Therapy of Brown Spider Envenomation: A Controlled Trial of Hyperbaric Oxygen, Dapsone, and Cyproheptadine

STUDY OBJECTIVE To determine whether hyperbaric oxygen (HBO), dapsone, or cyproheptadine decreases the severity of skin lesions resulting from experimental Loxosceles envenomation. DESIGN Randomized, blinded, controlled study. SETTING Animal care facility. INTERVENTIONS We used New Zealand white rabbits. All groups received 20 micrograms of pooled L deserta venom intradermally. Our control group received 4 ml of a 5% ethanol solution by oral gavage every 12 hours for 4 days. The HBO group received hyperbaric oxygen at 2.5 ATA for 65 minutes every 12 hours for 2 days, plus 5% ethanol solution for 4 days. The dapsone group received dapsone 1.1 mg/kg in 5% ethanol by gavage every 12 hours for 4 days. The cyproheptadine group received cyproheptadine .125 mg/kg in 5% ethanol by gavage every 12 hours for 4 days. RESULTS Total lesion size and ulcer size were followed for 10 days. The lesions were then excised, examined microscopically, and ranked by the severity of the histopathology. The groups did not differ significantly with respect to lesion size, ulcer size, or histopathologic ranking. CONCLUSION Given the negative result in this study with adequate power to detect meaningful treatment benefits, we cannot recommend hyperbaric oxygen, dapsone, or cyproheptadine in the treatment of Loxosceles envenomation.

Understanding the Direction of Bias in Studies of Diagnostic Test Accuracy

Ordering and interpreting diagnostic tests is a critical part of emergency medicine (EM). In evaluating a study of diagnostic test accuracy, emergency physicians (EPs) need to recognize whether the study uses case-control or cross-sectional sampling and account for common biases. The authors group biases in studies of test accuracy into five categories: incorporation bias, partial verification bias, differential verification bias, imperfect gold standard bias, and spectrum bias. Other named biases are either equivalent to these biases or subtypes within these broader categories. The authors go beyond identifying a bias and predict the direction of its effect on sensitivity and specificity, providing numerical examples from published test accuracy studies. Understanding the direction of a bias may permit useful inferences from even a flawed study of test accuracy.

Basal Cell Carcinoma Chemoprevention with Nonsteroidal Anti-inflammatory Drugs in Genetically Predisposed PTCH1+/− Humans and Mice

In vitro and epidemiologic studies favor the efficacy of nonsteroidal anti-inflammatory drugs (NSAID) in preventing skin squamous photocarcinogenesis, but there has been relatively little study of their efficacy in preventing the more common skin basal cell carcinoma (BCC) carcinogenesis. We first compared the relative anti-BCC effects of genetic deletion and NSAID pharmacologic inhibition of cyclooxygenase (COX) enzymes in the skin of Ptch1+/− mice. We then assessed the effects of celecoxib on the development of BCCs in a 3-year, double-blinded, randomized clinical trial in 60 (PTCH1+/−) patients with the basal cell nevus syndrome. In Ptch1+/− mice, genetic deletion of COX1 or COX2 robustly decreased (75%; P < 0.05) microscopic BCC tumor burden, but pharmacologic inhibition with celecoxib reduced microscopic BCCs less efficaciously (35%; P < 0.05). In the human trial, we detected a trend for oral celecoxib reducing BCC burden in all subjects (P = 0.069). Considering only the 60% of patients with less severe disease (<15 BCCs at study entry), celecoxib significantly reduced BCC number and burden: subjects receiving placebo had a 50% increase in BCC burden per year, whereas subjects in the celecoxib group had a 20% increase (Pdifference = 0.024). Oral celecoxib treatment inhibited BCC carcinogenesis in PTCH1+/− mice and had a significant anti-BCC effect in humans with less severe disease. Cancer Prev Res; 3(1); OF1–11

Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis

STUDY OBJECTIVE Ectopic pregnancy is a common concern in emergency departments (EDs) and remains the leading cause of first-trimester mortality. Pelvic ultrasonography by emergency physicians has been investigated as a diagnostic test for ectopic pregnancy. We present a meta-analysis of the use of emergency physician ultrasonography in the evaluation of patients at risk of ectopic pregnancy. METHODS A structured search was performed of both MEDLINE and EMBASE. Inclusion criteria were that (1) the study reported original research on ED patients at risk for ectopic pregnancy; (2) an emergency physician performed and interpreted the initial pelvic ultrasonography; and (3) follow-up was conducted on all patients. Sensitivity was defined as the proportion of patients with ectopic pregnancy for which ED ultrasonography demonstrated no intrauterine pregnancy. A random-effects model was used to obtain summary test characteristics. RESULTS The initial search showed 576 publications, abstract review yielded 60 with potential relevance, and 10 studies were included. There was a total of 2,057 patients, of whom 152 (7.5%) had ectopic pregnancy. The pooled sensitivity estimate was 99.3% (95% confidence interval [CI] 96.6% to 100%), negative predictive value was 99.96% (95% CI 99.6% to 100%), and negative likelihood ratio was 0.08 (95% CI 0.025 to 0.25), all without significant heterogeneity. CONCLUSION The results of this meta-analysis suggest that in a wide variety of clinical settings, the use of bedside ultrasonography performed by emergency physicians as a diagnostic test for ectopic pregnancy provides excellent sensitivity and negative predictive value. Visualization of an intrauterine pregnancy by an emergency physician is generally sufficient to rule out ectopic pregnancy.

Increasing discussions of intimate partner violence in prenatal care using Video Doctor plus Provider Cueing: a randomized, controlled trial.

PURPOSE To report the effectiveness of a prenatal intervention and to provide evidence that prenatal visits provide an opportune time for health assessment and counseling with abused women. METHODS Fifty ethnically diverse pregnant women who presented for routine prenatal care and who also reported being at risk for intimate partner violence (IPV) were recruited to the study. Participants were assigned to either usual care or the Video Doctor plus Provider Cueing intervention. At baseline and 1 month later at another routine prenatal visit, intervention group participants received a 15-minute Video Doctor assessment and interactive tailored counseling. Their providers received a printed Cue Sheet alert and suggested counseling statements. MAIN FINDINGS Participants in the intervention group were significantly more likely to report provider-patient discussions of IPV compared with participants receiving usual care at baseline (81.8% vs. 16.7%; p < .001) and at the 1-month follow-up (70.0% vs. 23.5%; p = .005). Summing the number of patient-provider discussions across the two visits at baseline and 1 month later, intervention participants were significantly more likely to have IPV risk discussion with their providers at one or both visits (90.0% vs. 23.6%; p < .001) compared with the participants who received usual care. When specifically asked about the helpfulness of these IPV-related discussions, 20 out of 22 (90.9%) participants rated the discussion as helpful or very helpful at baseline and all 18 (100%) participants rated the discussion as helpful or very helpful at the 1-month follow-up. CONCLUSION Video Doctor plus Provider Cueing intervention significantly increases the likelihood of provider-patient IPV discussion with pregnant women with a history of abuse.

Sex Differences in Statural Growth Impairment in Crohn’s Disease: Role of IGF-1

Background: Growth impairment in Crohns disease (CD) is more common in males than females for unknown reasons. Since insulin‐like growth factor‐1 (IGF‐1) is important for statural growth, we hypothesized that IGF‐1 levels are lower in males with CD. Methods: Sex differences in hormone Z‐scores based on chronological age (CA‐Z) and bone age (BA‐Z) were examined in a cross‐sectional study of 82 CD patients <21 years of age (43% female). Results: IGF‐1 CA‐Z and BA‐Z‐scores were 0.50 units (P = 0.04) and 1.24 units (P = 0.003) lower in males. Mean bone age (12.2 years) was lower than chronological age (13.1 years) (P < 0.0001). Erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP), and albumin did not differ by sex (P ≥ 0.08), but were associated with IGF‐1 CA‐Z and BA‐Z‐scores (P ≤ 0.02). Insulin‐like growth factor binding protein‐3 (IGFBP‐3) CA‐Z and BA‐Z‐scores were 0.71 units (P = 0.004) and 1.26 units (P < 0.001) lower in males. Inflammatory markers were correlated with sex hormone CA‐Z and BA‐Z and pituitary hormone BA‐Z‐scores in males (P ≤ 0.03), but not females (P ≥ 0.25). IGF‐1 BA‐Z‐scores were positively associated with height BA‐Z‐scores (P = 0.03). Mean height BA‐Z‐scores were lower in males (P = 0.03). Conclusions: Lower IGF‐1 levels in males may explain sex differences in growth impairment in CD. Inflammation appears to more adversely affect hormone levels and statural growth in males. Prospective longitudinal studies are needed to further clarify the role of IGF‐1 in sex differences in statural growth impairment in pediatric CD. (Inflamm Bowel Dis 2011;)

Rotational malreduction of the syndesmosis: reliability and accuracy of computed tomography measurement methods.

Background: Computed tomography (CT)-based indices may be superior to plain radiographs in determining the adequacy of reduction following operative fixation of the syndesmosis in unstable ankle fractures. This study assessed the reliability and accuracy of four CT-based methods for measurement of rotational malreduction of the fibula. Methods: A simulated Weber C ankle fracture was created by performing an osteotomy in 9 cadaver ankles. The fibula was rotated and fixed in neutral (0 degrees) and 10 to 30 degrees of internal and external rotation. Fifty-two CT images at the level of the syndesmosis were obtained in neutral and rotated positions and presented in random order to 3 independent observers. Measurements were made using commercial imaging software and 4 methods for interpreting CT scans. Interobserver reliability and accuracy were assessed and compared. Results: Methods 1 and 4 showed high anatomic variability. Methods 1, 2, and 4 had a test-retest repeatability of about 15 degrees. Method 1 varied erratically with direction and degree of malrotation (R2 = 0.15) and did not permit specification of a neutral range. Method 2 varied consistently and systematically with direction and degree of malrotation (R2 = 0.88). Receiver operating characteristic curve analysis indicated that method 2 identified malrotation better than did the other methods. Methods 3 and 4 were somewhat more difficult to perform. Conclusions: Method 2, the angle between the tangent of the anterior tibial surface and the bisection of the vertical midline of the fibula at the level of the incisura, was fairly reliable and accurate and had greater ease of measurement compared with the other methods that were tested. Clinical Relevance: This study demonstrated that assessment of malrotation of fibular fractures by CT scan can be difficult. We believe that of the 4 methods tested in this study, method 2, the angle between the tangent of the anterior tibial surface and the bisection of the vertical midline of the fibula at the level of the incisura, was the most useful.

Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared?

Objective To determine risk factors associated with infection and traumatic lacerations and to see if a relationship exists between infection and time to wound closure after injury. Methods Consecutive patients presenting with traumatic lacerations at three diverse emergency departments were prospectively enrolled and 27 variables were collected at the time of treatment. Patients were followed for 30 days to determine the development of a wound infection and desire for scar revision. Results 2663 patients completed follow-up and 69 (2.6%, 95% CI 2.0% to 3.3%) developed infection. Infected wounds were more likely to receive a worse cosmetic rating and more likely to be considered for scar revision (RR 2.6, 95% CI 1.7 to 3.9). People with diabetes (RR 2.70, 95% CI 1.1 to 6.5), lower extremity lacerations (RR 4.1, 95% CI 2.5 to 6.8), contaminated lacerations (RR 2.0, 95% CI 1.2 to 3.4) and lacerations greater than 5 cm (RR 2.9, 95% CI 1.6 to 5.2) were more likely to develop an infection. There were no differences in the infection rates for lacerations closed before 3% (95% CI 2.3% to 3.8%) or after 1.2% (95% CI 0.03% to 6.4%) 12 h. Conclusions Diabetes, wound contamination, length greater than 5 cm and location on the lower extremity are important risk factors for wound infection. Time from injury to wound closure is not as important as previously thought. Improvements in irrigation and decontamination over the past 30 years may have led to this change in outcome.

Promoting smoking cessation in pregnancy with Video Doctor plus provider cueing: a randomized trial.

Objective. This study examined the use of a Video Doctor plus provider cueing to promote provider advice and smoking cessation outcomes in pregnancy. Design. A randomized clinical trial was conducted from 2006 to 2008. Setting. Five community prenatal clinics in the San Francisco Bay Area of the United States. Participants. A total of 410 pregnant patients completed screening for behavioral risks including tobacco use in the past 30 days. Pregnant smokers (n = 42) were randomized regardless of their intention to quit smoking. Methods. Participants were assigned to either usual care or intervention. Intervention participants received 15‐minute Video Doctor sessions plus provider cueing, at baseline and one month, prior to their routine prenatal visit. The Video Doctor delivered interactive tailored messages, an educational worksheet for participants, and a cueing sheet for providers. Main outcome measures. Receipt of advice from the provider and 30‐day smoking abstinence, both by self‐report. Results. Intervention participants were more likely to receive provider advice on tobacco use at both prenatal visits during the intervention period (60.9 vs. 15.8%, p = 0.003). The intervention yielded a significantly greater decrease in the number of days smoked and in cigarettes smoked per day. The 30‐day abstinence rate at two months post baseline was 2.5 times greater in the intervention group; the difference was not significant (26.1 vs. 10.5%, p = 0.12). Conclusions. The Video Doctor plus provider cueing is an efficacious adjunct to routine prenatal care by promoting provider advice and smoking reduction among pregnant smokers.